Revenue Cycle Insider

Question: A 61-year-old patient with recurrent nephrolithiasis presented to the urologist with acute left flank pain. The in-house radiologist performed a noncontrast CT scan of the abdomen and pelvis. The report lists the findings as a 5 mm distal left ureteral calculus causing mild left hydroureter and mild hydronephrosis.

How should we report the encounter?

Oklahoma Subscriber

Answer: You’ll assign 74176 (Computed tomography, abdomen and pelvis; without contrast material) for the CT scan of the abdomen and pelvis without contrast material. Coders might want to assign separate CPT^® codes for CT scans of each body area, such as 74150 (Computed tomography, abdomen; without contrast material) and 72192 (Computed tomography, pelvis; without contrast material); but this is incorrect according to the CPT^® guidelines. The guidelines instruct you to use the corresponding combination code for “combinations of CT of the abdomen with CT of the pelvis performed at the same session.”

Next, you’ll turn to the ICD-10-CM code set to report the findings. The CT demonstrated a distal ureteral stone (calculus) causing an obstruction in the urinary tract, such as hydronephrosis and hydroureter. Use N13.2 (Hydronephrosis with renal and ureteral calculous obstruction) to capture the obstruction and hydronephrosis. This is a combination code illustrating that the stone is the cause of the documented condition.

With both the CPT^® coding and the ICD-10-CM coding, if you were to assign separate codes — such as CT abdomen and CT pelvis as well as hydronephrosis and ureteral calculus — you’d overcode your claim, which could put you at risk of a claim denial or an audit.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC